Emphysematous Gastritis: A Rare and Lethal Cause of Severe Abdominal Pain

Abstract

Introduction: Emphysematous gastritis (EG) is an exceedingly rare cause of severe abdominal pain with an associated mortality reported at greater than 60%. We present 3 cases of EG at our hospital over the course of one year. Case 1: 68-year-old male with a history of osteoarthritis on chronic excessive doses of ibuprofen presented with a subdural hematoma due to a mechanical fall and a urinary tract infection (UTI). While hospitalized, the patient developed severe, diffuse abdominal pain, nausea, and worsening leukocytosis despite appropriate antibiotic coverage for his UTI. An abdominal CT revealed signs of EG. Case 2: 62-year-old woman who underwent a laparoscopic paraesophageal hernia repair with Nissen fundoplication and gastropexy presented postoperatively with one day of severe epigastric pain, pleuritic chest pain, and leukocytosis. Originally thought to have gastroparesis, initial therapy with metoclopramide was ineffective. Further evaluation with abdominal CT revealed signs of EG. Case 3: 84-year-old male with history of diabetes and ischemic stroke presented with multiple days of diarrhea, coffee ground emesis and severe epigastric pain. He was admitted for upper gastrointestinal bleed work up. Prior to performing EGD, he decompensated and was transitioned to the ICU on mechanical ventilation. A worsening leukocytosis prompted abdominal CT, revealing signs of EG. Results: The findings common to all presentations were worsening leukocytosis, abdominal pain, and imaging revealing air in the gastric wall and portovenous system. The first case was managed with broad spectrum antibiotics and bowel rest. Upper endoscopy (EGD) confirmed a large ulcer in the fundus and body, that resolved on follow-up EGD. The second case had an EGD showing severe gastritis, and patient improved with no further intervention or antibiotics. The third case expired after multiple days of broad spectrum antibiotics and was too unstable to undergo EGD or surgery. Discussion: EG is characterized by severe abdominal pain and leukocytosis with imaging confirming intramural gastric air and portovenous air. Risk factors associated with EG include high dose NSAIDs and gastric surgery. CT scan is imperative for early diagnosis and distinguishing from other etiologies, as EG can be rapidly lethal. EGD can be performed despite the CT findings which can reveal varying degrees of inflammation. It is unclear if empiric treatment with antibiotics may have a significant benefit.